Published online Mar 16, 2015. doi: 10.12998/wjcc.v3.i3.265
Peer-review started: July 23, 2014
First decision: September 2, 2014
Revised: November 24, 2014
Accepted: January 15, 2015
Article in press: January 19, 2015
Published online: March 16, 2015
Processing time: 233 Days and 11.1 Hours
Robotic surgery is increasingly being employed to overcome the disadvantages associated with use of conventional techniques such as laparoscopy. However, despite significant promise, there are some clear disadvantages and robust evidence base supporting the use of robotic assistance remains lacking. In this paper, the advantages and drivers for robotics will be discussed, its drawbacks and its future role in surgery.
Core tip: Robotic technology is increasingly being employed in surgery to overcome the disadvantages associated with use of conventional techniques such as laparoscopy. However, despite significant promise, robust evidence base supporting the use of robotic assistance remains lacking. Prospective, multicentre randomised controlled trials to evaluate efficacy, long-term outcomes, safety and cost are the next steps before widespread uptake of this technology to treat patients. Moreover, with the unprecedented need for patient safety, it is imperative that adequate training and assessment strategies are in place to bridge the gap between conventional techniques and robotic surgery without harm to patients.
- Citation: Khajuria A. Robotics and surgery: A sustainable relationship? World J Clin Cases 2015; 3(3): 265-269
- URL: https://www.wjgnet.com/2307-8960/full/v3/i3/265.htm
- DOI: https://dx.doi.org/10.12998/wjcc.v3.i3.265
Robotic surgery is increasingly being implemented to overcome drawbacks associated with the use of conventional techniques such as laparoscopy, especially in complex procedures. However, despite holding significant promise, robotic surgery is associated with some clear disadvantages and robust evidence base supporting robotic assistance remains lacking[1].
The introduction of minimally invasive techniques to general surgery has been described as “the most dramatic change in surgery since the introduction of anaesthesia”[2]. This has led to many procedures being performed exclusively via the laparoscopic approach, such as a cholecystectomy. Reasons include reduced blood loss and post-operative pain, reduced risk of infection, reduced length of hospital stay and faster return to daily activities[3]. However, these superior results are only when the initial learning curve has been taken into account.
Laparoscopic surgery is associated with several challenges. Disadvantages and complications have been well documented[4]. Long, rigid instruments amplify tremor, reduce range of motion and degrees of freedom. This is exacerbated by the fulcrum effect whereby instrument tips move in a direction opposite to those of surgeon’s hands[5]. Loss of 3-dimentional (3D) vision and having to view a 2-dimentional image, not directly under the control of surgeon, enhances these difficulties by leading to loss of traditional eye-hand target axis[6]. The laparoscopic technique is associated with poor ergonomics and health problems in surgeons such as nerve injuries[7]. Robotic systems, such as the da Vinci, have thus emerged to overcome few of these limitations.
The 3D, high-definition imaging of robotic technology facilitates stereotactic vision of the operation field and makes depth perception possible[8]. The camera is surgeon-controlled and the area of interest can be magnified up to 10 times. The surgeon’s hand movements can be scaled (5:1, 3:1, or 1:1) so that large hand movements are translated into smaller movements inside the patient[9]. Combined with tremor abolition, this facilitates precise surgical manoeuvres. Endowrist instrumentation provides 7 degrees of freedom and improves range of motion, enhancing dexterity, comparable to that attained in open procedures[10]. The surgeon’s comfort is increased by the ergonomic sitting position, reducing fatigue (both physical and cognitive) due to exhausting positions or movements often observed in conventional laparoscopy[11]. The intuitive movements in robotic surgery can potentially shorten the learning curve compared to conventional laparoscopy[12]. Thus, less experienced laparoscopic surgeons may acquire skills to conduct robotic surgeries in a relatively shorter time period compared to attaining corresponding proficiency in conventional laparoscopy. Significant progress in robotic applications has been in procedures that cannot be performed by a laparoscopic approach, i.e., cardiac and endovascular surgery.
A Total Endoscopic Coronary Artery Bypass (TECAB) can now be performed using the robotic slave system, da Vinci, from the Left Internal Mammary Artery to the Left Anterior Descending artery without the need for a strenotomy[13]. Successful results have been reported by several groups as a result of reduced post-operative pain, better cosmesis and faster healing due to lack of a strenotomy incision[14]. Procedures requiring extreme precision or fine visualisation, such as coronary anastomosis are facilitated by the high magnification and tremor-free, precise microinstrumentation[15]. Greater patient satisfaction is also reported[16]. Off-pump procedures (i.e., on a beating heart) avoid complications of cardiopulmonary bypass and are associated with a lower incidence of atrial fibrillation, stroke and death in the elderly[17]. Robotic surgery is also useful for mitral valve reconstruction. 3D visualisation allows good view of the ventricle needed for suturing in chordal reconstruction[18]. Greater range of motion facilitates the complex cutting and needle loading angles in the confined space of the left atrium[18].
However, there are disadvantages. Robot-assisted TECAB is a technically demanding and time-consuming procedure. It is associated with a significant learning curve[19]. Nevertheless, it represents a feasible alternative to conventional coronary artery bypass[20].
Another emerging domain of robotic surgery is that of endovascular robotics. The conventional endovascular catheters present several limitations within the vascular tree. These include their small range of shapes and sizes, difficulty in maneuvering the tip with the lack of stability[21]. Hence, interventionalists have to frequently change catheters and this presents a major risk of vessel trauma or distal embolization as a result of alteration of guidewire position[21]. This is especially critical in the aortic arch, where stroke, as a result of cerebral embolisation, may occur[21].
Riga et al[22] demonstrated that Endovascular Aneurysm Repair using a robotically steerable catheter system is feasible and may improve catheter maneuverability, stability and precision. Pre-shaped conventional catheters can rotate around one axis only, presenting a major drawback when fine and controlled movements are required in multiple planes[22]. Conversely, a steerable multidirectional catheter may overcome this hurdle and may be especially useful with regards to anatomically difficult cannulation in fenestrated stent-grafting[23]. This system also minimises operator radiation exposure, as the workstation is located outside the endovascular suite and away from the radiation source. Robotic endovascular catheters may lead to improved accuracy, reduce time and minimise radiation exposure in complex vascular procedures in particular[23]. Moreover, robotic endovascular catheters have been demonstrated to lead to a statistically significant faster skill acquisition in novice surgeons[24]. Hence, there is a potential to shorten the learning curve so that trainees can attempt more complex endovascular procedures earlier and with a greater degree of safety[24]. Yet, transferability of these findings to the operating room (OR) is debatable.
Despite the numerous advantages, robotics in surgery has drawbacks that hinder the widespread implementation of its usage (Table 1). In particular, the evidence base supporting robotic assistance remains lacking[1]. This extends beyond the examples provided above. A robotic prostatectomy is now the standard of care in many centres; despite only one RCT and substantial publication and selection bias, the results have showed no significant improvement in patient morbidity compared with conventional laparoscopy[25]. Likewise, a Cochrane review showed no differences in safety and efficacy for benign gynaecological robotic surgery compared to conventional laparoscopy[26].
Drawback | Discussion |
Cost | The da Vinci system costs approximately $1.5 million with maintenance fees of about $150000 per year[43,44]. Likewise, robotic endovascular catheter systems are expensive, have high maintenance costs, with the additional cost of disposable catheters. However, there is no conclusive data regarding the cost-effectiveness of these robotic systems. Moreover, an economic model, with quality of life adjustment, has not been performed for any of the robotic systems[44] |
Evidence | Currently, the evidence for robotic surgery’s efficacy and safety is largely from retrospective studies often with small sample sizes or from an institution’s initial cases/experiences, where the surgeon may be at the start of his/her learning curve[44]. Hence, conclusions about safety and efficacy must be interpreted with caution |
Preparation, floor space and emergencies | The Theatre team must also be trained with the device set-up including troubleshooting problems that may arise during operations. Hence, the robotic surgery venture is likely a time, cost and resource-intensive process[45]. Moreover, considerable floor space is needed, with bulky instruments; this may be problematic and considerable cost may be incurred for renovations before robotic surgery can be employed. Furthermore, in an emergency, there may be a delay in converting to an open procedure since the bulky instruments cannot be as easily removed as in conventional laparoscopy[44] |
Unproven efficacy | Current evidence base for efficacy of robotic surgery is mainly from small, retrospective studies. Prospective, multicentre randomized clinical trials to evaluate safety, efficacy, long term outcomes and cost analysis are required to prove that robotic assistance is indeed superior to conventional techniques before its widespread use |
Results from high quality, prospective, multi-centre randomized clinical trials (RCTs) are urgently required to evaluate the true efficacy of robotic surgery. Enhanced patient care may justify any higher costs. For surgeons uncomfortable with advanced conventional techniques, robotic surgery may reduce the time for them to reach procedure proficiency. For experienced surgeons, robotic surgery may enhance precision and decrease physical and mental workload.
With an unprecedented need for patient safety[27], it is imperative that adequate training and assessment strategies are in place to bridge the gap between conventional techniques and robotic surgery without harm to patients. This is especially important now with reduced working hours and training opportunities following calmanisation and introduction of the European Working Time Directive[28]. Possible avenues include: (1) Virtual Reality (VR) simulation; (2) Use of dual consoles; and (3) Training courses.
VR simulation has been well established for conventional laparoscopy and has shown to improve skill transfer to the operating room[29,30]. However, its effectiveness in robotic surgery is less clear[31]. Before a simulator is used, it must fulfil a criterion with regards to validity and reliability (Table 2)[31]. Indeed, a study by Hung et al[32,33] showed that the da Vinci Skills Simulator demonstrated content, face and construct validity. The performance of the expert group was superior to intermediate/novice group when evaluating parameters such as overall score, motion economy and time to completion[32]. Specific proficiency-based curricula need to be developed in order to provide structured training with in built measures of assessment. However, while VR simulation for Robotic Surgical Training is a promising tool, data on skills transfer to the operating room is still lacking and further work is required before we can draw any firm conclusions about its efficacy in training. Another promising strategy is use of a dual console.
Type | Definition |
Face Validity | Extent to which the simulator resembles real life scenarios |
Content Validity | Extent to which the domain that is being measured is being measured by the simulator/assessment tool |
Construct Validity | Extent to which a simulator measures the trait it purports to measure |
Concurrent Validity | Extent to which the results of the assessment tool correlate with the gold standard for that domain |
Predictive Validity | Ability of the simulator to predict future performance |
Test-Retest Reliability | Measure of a test to generate similar results when applied at two different points |
Inter-Rater Reliability | Measure of agreement between two or more observers when rating an individual’s performance |
The dual console allows collaboration between the trainee and an experienced mentor[31]. There are two collaborative modes: (1) “Swap mode” enables the experienced surgeon and the trainee to operate in parallel and switch control of the robotic arms; this facilitates parts of the operation requiring multiple hands, for example vessel isolation[31,33]; and (2) “Nudge mode” enables trainee and mentor to share the two robotic arms which is useful during key parts of the operation whereby the mentor can guide the hands of the trainee[31,33,34]. Marengo et al[35] suggested that use of dual consoles might shorten the learning curve and increase trainees’ confidence in performing procedures. However, the data for the efficacy of dual consoles is scarce and prospective, RCTs are required to evaluate their true efficacy in surgical training[31].
Training courses, using animal, inanimate or cadaveric models have shown promise[31]. Assessment parameters include time to setup and operate, complications, errors and quality as determined by the Objective Structured Assessment of Technical Skills score[34,36]. Dulan et al[37] have developed a proficiency-based robotic training program that demonstrates construct and content validity as well as feasibility. Further validation of such curricula should be encouraged since we know that for conventional laparoscopy, achieving proficiency ascertains whether a surgeon has the aptitude to perform a procedure; this is not related to the length of training[38]. Aggarwal et al[39] demonstrated that a proficiency-based curriculum for laparoscopic cholecystectomy could shorten the learning curve resulting in faster skill acquisition. Moreover, such curricula for robotic surgery may provide the opportunity to exercise deliberate practice that has been regarded as a key practice to enhance and acquire “expert performance”[40,41]. And crucially, proficiency-based curricula may allow standardisation in training and assessment[39].
Finally, future development and innovation in more advanced technology for procedures that are challenging to perform with conventional as well as current robotic technology is warranted with the ultimate aim of improving patient outcome. The new imaging-sensing-navigated, kinematically enhanced robot, a flexible-access robot with integrated multimodal and multi-scale sensing, can enable the surgeon to guide tools into regions of the body that are difficult to access with the current technology[42]. It has already shown promising results in vivo, with clinical translation planned in the next couple of years[42].
Like when laparoscopic surgery was introduced, establishing the role of robotic surgery will take time and to ascertain which patients are most likely to benefit from it. Prospective, multicentre randomised controlled trials to evaluate efficacy, long-term outcomes, safety and cost are the next steps before widespread uptake of this technology to treat patients.
P- Reviewer: Chow WK, Seow-Choen F S- Editor: Tian YL L- Editor: A E- Editor: Lu YJ
1. | Sodergren MH, Darzi A. Robotic cancer surgery. Br J Surg. 2013;100:3-4. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 21] [Cited by in F6Publishing: 22] [Article Influence: 1.8] [Reference Citation Analysis (0)] |
2. | Royston CM, Lansdown MR, Brough WA. Teaching laparoscopic surgery: the need for guidelines. BMJ. 1994;308:1023-1025. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 41] [Cited by in F6Publishing: 44] [Article Influence: 1.5] [Reference Citation Analysis (0)] |
3. | Agha R, Muir G. Does laparoscopic surgery spell the end of the open surgeon? J R Soc Med. 2003;96:544-546. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 15] [Cited by in F6Publishing: 28] [Article Influence: 1.4] [Reference Citation Analysis (0)] |
4. | Duca S, Bãlã O, Al-Hajjar N, Lancu C, Puia IC, Munteanu D, Graur F. Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB (Oxford). 2003;5:152-158. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 21] [Cited by in F6Publishing: 22] [Article Influence: 1.4] [Reference Citation Analysis (0)] |
5. | Bittner JG, Hathaway CA, Brown JA. [In Process Citation]. J Minim Access Surg. 2008;4:31-38. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 14] [Cited by in F6Publishing: 15] [Article Influence: 0.9] [Reference Citation Analysis (0)] |
6. | Aggarwal R, Hance J, Darzi A. Robotics and surgery: a long-term relationship? Int J Surg. 2004;2:106-109. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 12] [Cited by in F6Publishing: 13] [Article Influence: 0.8] [Reference Citation Analysis (0)] |
7. | Supe AN, Kulkarni GV, Supe PA. Ergonomics in laparoscopic surgery. J Minim Access Surg. 2010;6:31-36. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 78] [Cited by in F6Publishing: 81] [Article Influence: 6.2] [Reference Citation Analysis (1)] |
8. | Mylonas GP, Darzi A, Yang GZ. Gaze-contingent control for minimally invasive robotic surgery. Comput Aided Surg. 2006;11:256-266. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 29] [Cited by in F6Publishing: 29] [Article Influence: 1.7] [Reference Citation Analysis (0)] |
9. | Prasad SM, Prasad SM, Maniar HS, Chu C, Schuessler RB, Damiano RJ. Surgical robotics: impact of motion scaling on task performance. J Am Coll Surg. 2004;199:863-868. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 95] [Cited by in F6Publishing: 66] [Article Influence: 3.5] [Reference Citation Analysis (0)] |
10. | Kumar R, Hemal AK. Emerging role of robotics in urology. J Minim Access Surg. 2005;1:202-210. [PubMed] [DOI] [Cited in This Article: ] [Cited by in F6Publishing: 10] [Reference Citation Analysis (0)] |
11. | van der Schatte Olivier RH, Van’t Hullenaar CD, Ruurda JP, Broeders IA. Ergonomics, user comfort, and performance in standard and robot-assisted laparoscopic surgery. Surg Endosc. 2009;23:1365-1371. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 120] [Cited by in F6Publishing: 115] [Article Influence: 7.2] [Reference Citation Analysis (0)] |
12. | Chandra V, Nehra D, Parent R, Woo R, Reyes R, Hernandez-Boussard T, Dutta S. A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery. 2010;147:830-839. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 168] [Cited by in F6Publishing: 163] [Article Influence: 10.9] [Reference Citation Analysis (0)] |
13. | Kappert U, Schneider J, Cichon R, Gulielmos V, Schade I, Nicolai J, Schueler S. Closed chest totally endoscopic coronary artery bypass surgery: fantasy or reality? Curr Cardiol Rep. 2000;2:558-563. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 15] [Cited by in F6Publishing: 15] [Article Influence: 0.6] [Reference Citation Analysis (0)] |
14. | Bonatti J, Schachner T, Bonaros N, Lehr EJ, Zimrin D, Griffith B. Robotically assisted totally endoscopic coronary bypass surgery. Circulation. 2011;124:236-244. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 65] [Cited by in F6Publishing: 72] [Article Influence: 5.5] [Reference Citation Analysis (0)] |
15. | Boyd WD, Desai ND, Kiaii B, Rayman R, Menkis AH, McKenzie FN, Novick RJ. A comparison of robot-assisted versus manually constructed endoscopic coronary anastomosis. Ann Thorac Surg. 2000;70:839-842; discussion 842-843. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 44] [Cited by in F6Publishing: 45] [Article Influence: 1.9] [Reference Citation Analysis (0)] |
16. | Deeba S, Aggarwal R, Sains P, Martin S, Athanasiou T, Casula R, Darzi A. Cardiac robotics: a review and St. Mary’s experience. Int J Med Robot. 2006;2:16-20. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 15] [Cited by in F6Publishing: 18] [Article Influence: 1.1] [Reference Citation Analysis (0)] |
17. | Panesar SS, Athanasiou T, Nair S, Rao C, Jones C, Nicolaou M, Darzi A. Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting--comparison between off-pump and on-pump techniques. Heart. 2006;92:1808-1816. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 83] [Cited by in F6Publishing: 90] [Article Influence: 5.0] [Reference Citation Analysis (0)] |
18. | Atluri P, Woo YJ. Minimally invasive robotic mitral valve surgery. Expert Rev Med Devices. 2011;8:115-120. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 9] [Cited by in F6Publishing: 10] [Article Influence: 0.8] [Reference Citation Analysis (0)] |
19. | Bonatti J, Schachner T, Bernecker O, Chevtchik O, Bonaros N, Ott H, Friedrich G, Weidinger F, Laufer G. Robotic totally endoscopic coronary artery bypass: program development and learning curve issues. J Thorac Cardiovasc Surg. 2004;127:504-510. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 88] [Cited by in F6Publishing: 92] [Article Influence: 4.6] [Reference Citation Analysis (0)] |
20. | Acharya MN, Ashrafian H, Athanasiou T, Casula R. Is totally endoscopic coronary artery bypass safe, feasible and effective? Interact Cardiovasc Thorac Surg. 2012;15:1040-1046. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 3] [Cited by in F6Publishing: 3] [Article Influence: 0.3] [Reference Citation Analysis (0)] |
21. | di Marco A, Riga C, Hamady M, Cheshire N, Bicknell C. Robotic and Navigational Technologies in Endovascular Surgery. Vascular Disease Management. 2010;7:E15-E19. [Cited in This Article: ] |
22. | Riga C, Bicknell C, Cheshire N, Hamady M. Initial clinical application of a robotically steerable catheter system in endovascular aneurysm repair. J Endovasc Ther. 2009;16:149-153. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 48] [Cited by in F6Publishing: 38] [Article Influence: 2.5] [Reference Citation Analysis (0)] |
23. | Riga CV, Cheshire NJ, Hamady MS, Bicknell CD. The role of robotic endovascular catheters in fenestrated stent grafting. J Vasc Surg. 2010;51:810-819; discussion 819-820. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 52] [Cited by in F6Publishing: 47] [Article Influence: 3.4] [Reference Citation Analysis (0)] |
24. | Riga CV, Bicknell CD, Sidhu R, Cochennec F, Normahani P, Chadha P, Kashef E, Hamady M, Cheshire NJ. Advanced catheter technology: is this the answer to overcoming the long learning curve in complex endovascular procedures. Eur J Vasc Endovasc Surg. 2011;42:531-538. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 30] [Cited by in F6Publishing: 30] [Article Influence: 2.3] [Reference Citation Analysis (0)] |
25. | Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, Guazzoni G, Guillonneau B, Menon M, Montorsi F. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009;55:1037-1063. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 731] [Cited by in F6Publishing: 698] [Article Influence: 46.5] [Reference Citation Analysis (0)] |
26. | Liu H, Lu D, Wang L, Shi G, Song H, Clarke J. Robotic surgery for benign gynaecological disease. Cochrane Database Syst Rev. 2012;2:CD008978. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 35] [Cited by in F6Publishing: 55] [Article Influence: 4.6] [Reference Citation Analysis (0)] |
27. | Kohn L. To err is human: an interview with the Institute of Medicine’s Linda Kohn. Jt Comm J Qual Improv. 2000;26:227-234. [PubMed] [Cited in This Article: ] |
28. | Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. BMJ. 2004;328:418-419. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 217] [Cited by in F6Publishing: 216] [Article Influence: 10.8] [Reference Citation Analysis (0)] |
29. | Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, Satava RM. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236:458-463; discussion 463-464. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 1953] [Cited by in F6Publishing: 1670] [Article Influence: 75.9] [Reference Citation Analysis (0)] |
30. | Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg. 2004;91:146-150. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 902] [Cited by in F6Publishing: 797] [Article Influence: 39.9] [Reference Citation Analysis (0)] |
31. | Buchs NC, Pugin F, Volonté F, Morel P. Learning tools and simulation in robotic surgery: state of the art. World J Surg. 2013;37:2812-2819. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 28] [Cited by in F6Publishing: 18] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
32. | Hung AJ, Zehnder P, Patil MB, Cai J, Ng CK, Aron M, Gill IS, Desai MM. Face, content and construct validity of a novel robotic surgery simulator. J Urol. 2011;186:1019-1024. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 145] [Cited by in F6Publishing: 146] [Article Influence: 11.2] [Reference Citation Analysis (0)] |
33. | Hung AJ, Patil MB, Zehnder P, Cai J, Ng CK, Aron M, Gill IS, Desai MM. Concurrent and predictive validation of a novel robotic surgery simulator: a prospective, randomized study. J Urol. 2012;187:630-637. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 88] [Cited by in F6Publishing: 76] [Article Influence: 5.8] [Reference Citation Analysis (0)] |
34. | Hanly EJ, Miller BE, Kumar R, Hasser CJ, Coste-Maniere E, Talamini MA, Aurora AA, Schenkman NS, Marohn MR. Mentoring console improves collaboration and teaching in surgical robotics. J Laparoendosc Adv Surg Tech A. 2006;16:445-451. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 41] [Cited by in F6Publishing: 44] [Article Influence: 2.9] [Reference Citation Analysis (0)] |
35. | Marengo F, Larraín D, Babilonti L, Spinillo A. Learning experience using the double-console da Vinci surgical system in gynecology: a prospective cohort study in a University hospital. Arch Gynecol Obstet. 2012;285:441-445. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 28] [Cited by in F6Publishing: 28] [Article Influence: 2.2] [Reference Citation Analysis (0)] |
36. | Narazaki K, Oleynikov D, Stergiou N. Robotic surgery training and performance: identifying objective variables for quantifying the extent of proficiency. Surg Endosc. 2006;20:96-103. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 58] [Cited by in F6Publishing: 52] [Article Influence: 2.7] [Reference Citation Analysis (0)] |
37. | Dulan G, Rege RV, Hogg DC, Gilberg-Fisher KM, Arain NA, Tesfay ST, Scott DJ. Developing a comprehensive, proficiency-based training program for robotic surgery. Surgery. 2012;152:477-488. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 88] [Cited by in F6Publishing: 82] [Article Influence: 6.8] [Reference Citation Analysis (0)] |
38. | Aggarwal R, Darzi A, Grantcharov TP. Re: A systematic review of skills transfer after surgical simulation training. Ann Surg. 2008;248:690-691; author reply 691. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 7] [Cited by in F6Publishing: 10] [Article Influence: 0.6] [Reference Citation Analysis (0)] |
39. | Aggarwal R, Grantcharov T, Moorthy K, Milland T, Papasavas P, Dosis A, Bello F, Darzi A. An evaluation of the feasibility, validity, and reliability of laparoscopic skills assessment in the operating room. Ann Surg. 2007;245:992-999. [PubMed] [Cited in This Article: ] |
40. | Crochet P, Aggarwal R, Dubb SS, Ziprin P, Rajaretnam N, Grantcharov T, Ericsson KA, Darzi A. Deliberate practice on a virtual reality laparoscopic simulator enhances the quality of surgical technical skills. Ann Surg. 2011;253:1216-1222. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 119] [Cited by in F6Publishing: 131] [Article Influence: 10.1] [Reference Citation Analysis (0)] |
41. | Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15:988-994. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 888] [Cited by in F6Publishing: 818] [Article Influence: 51.1] [Reference Citation Analysis (0)] |
42. | Monaco A. The Next Generation of Surgical Robots. The Institute. Available from: http:/theinstitute.ieee.org/technology-focus/technology-topic/the-next-generation. [Cited in This Article: ] |
43. | Monod P. Financial aspects, or how to use a robot assistance without losing money. Perspectives from private practice. J Visc Surg. 2011;148:e22-e26. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 1] [Cited by in F6Publishing: 1] [Article Influence: 0.1] [Reference Citation Analysis (0)] |
44. | De Wilde RL, Herrmann A. Robotic surgery - advance or gimmick? Best Pract Res Clin Obstet Gynaecol. 2013;27:457-469. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 6] [Cited by in F6Publishing: 8] [Article Influence: 0.7] [Reference Citation Analysis (0)] |
45. | Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective. Ann Surg. 2004;239:14-21. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 761] [Cited by in F6Publishing: 640] [Article Influence: 32.0] [Reference Citation Analysis (0)] |